Table of Contents

VOLUME I

EXECUTIVE SUMMARY

SECTION I. ORGANIZATIONAL FUNCTIONS

1. Purposes 

A. Mission

B. Vision

C. Values

D. Goals

E. Objectives

F. Code of Ethics

G. Services

2. Governing Body 

A. Responsibilities

B. Organization

C. Organizational Structure

D. Chief Executive Officer

E. Conflict of Interest

3. Administration

A. Principles

B. Administrator

C. Director of Insurance

D. Staff Recruitment and Retention

E. Licensure and Certification

F. Job Performance Review

G. Information Management

4. Fiscal Management

A. Principles

B. Financial Records

C. Business Procedures

D. Collections

E. Financial Expenditures

5. Administrative Policies

A. Smoking Policy

B. Non-Discrimination

C. Use of Outside Resources

D. Review of Contract Services

E. Loss or Theft of Property or Money

F. Solicitation and Distribution of Literature

G. Visitor Injury/Mishap

H. Incident Reports

6. Medical Staff 

A. Goals

B. Objectives

C. Organization of Medical Staff

D. Medical Staff Membership

E. Medical Staff Credentialing

F. Medical Staff Executive Committee

G. Medical Staff Management

H. Impaired Physician

I. Independent Clinical Staff

J. Patient Management

SECTION II. PATIENT FOCUSED FUNCTIONS

1. Purposes 

A. Principles

B. Patient's Bill of Rights

C. Patient Responsibilities

2. Patient Rights

A. Patient Complaints

B. Informed Decision Making

C. Access to Medical Records

D. Informed Consent

E. Patient Confidentiality

F. Confidential Messages

G. Patient Valuables

H. Discrimination Policy

I. Patient Directives

J. Care of Terminally Ill Patient

K. Research and Experimentation

L. Speech or Hearing Impaired Patients

3. Patient Consent

A. Consent Policy

B. Consent for Operation and Invasive Procedures

C. Consent for Sterilization

D. Consent - HIV Testing

E. Consent to Photograph

4. Patient Abuse

5. Patient Management 

A. Patient Admission Policies

B. Storage of Medications

C. Emergency Carts

D. Patient/Family Education

E. Continuum of Care

F. Patient Transport

G. Discharge Against Medical Advice

H. Protection of Patients From Hazardous Materials

I. Restraints and Seclusion

J. Death at the Center

SECTION III HUMAN RESOURCES

1. General Principles

A. General Policies

B. Employment

C. Personnel Records

D. Classification of Employees

E. Performance

F. Verification and Control Systems

G. Confidentiality

H. Dress Regulations

I. Attendance

J. Employee Communication

K. Work/Salary

L. New Employee Orientation

M. Employee Requests for Time Off

N. In-Service Education Program

O. Sexual Harassment

P. Personal Telephone Calls

Q. Disciplinary Procedure

R. Termination of Employment

2. Employee Health

A. Objectives

B. Employee Health Program

C. Exposure Control Plan

D. Tuberculosis Screening Program

E. Immunizations

F. Post Exposure Prophylaxis of Hepatitis

G. Exposure to HIV.

H. Exposure to Meningococcal Meningitis.

I. Illness Reporting

J. General Safety for All Employees

K. Reporting Injury on the Job

L. Worker's Compensation

3. Policies of Administrative Personnel

A. Director of Public Relations

B. Chief Transcriptionist

C. Admissions Coordinator

D. Medical Records Coordinator

E. Director of Maintenance and Safety

F. Transcriptionist

G. Insurance Coordinator

H. Admissions Clerk/Receptionist

I. Medical Records Clerk

J. Administrative Assistant

4. Policies of Nursing Personnel

A. General Policies

B. Nursing Administrator

C. Clinical Coordinator

D. Employee Health Nurse

E. Staff Nurse

F. Staff Nurse - Recovery

G. Licensed Practical Nurse

H. Nurses' Aide

5. Policies of Professional Personnel

A. Surgical Technologist

B. Radiologic Technologist

C. Registered Nurse Anesthetist

D. Nurse Practitioner

E. PhysicianÍs Assistant

6. Policies of Physician Personnel

A. Medical Director

B. Director of Anesthesia

C. Physician

D. Anesthesiologist

7. Ancillary Personnel

A. Statistician and Programmer

B. Janitor

C. Laundry Coordinator

8. Education and Training

A. General Policies

B. Educational Profiles

C. Cardiopulmonary Resuscitation Certification

D. Continuing Education

VOLUME TWO

SECTION IV ENVIRONMENTAL SAFETY

1. Purposes

A. Principles

B. Physical Facilities

C. Risk Management 

2. Fire Safety

A. Introduction

B. Prevention of Fire in an Oxygen Enriched Atmosphere

C. Evacuation Procedures

D. Responsibilities, Admissions Coordinator

3. General Safety

A. Statement of Policy

B. Safety Education

C. Safety Surveillance Program

4. Environmental Control

A. Safety

B. Departmental Safety, Laundry

C. Departmental Safety, Business Office, Front Desk

D. Departmental Safety, Laboratory

E. Departmental Safety, Medical Records

F. Departmental Safety, Nursing Department

G. Departmental Safety, Maintenance

H. Departmental Safety, Radiology

I. Departmental Safety, Pharmacy

J. Medical Device Problem and Recall

5. Emergency Preparedness

A. Preface

B. Emergency Response

C. Bomb Threat

D. Earthquake

E. Explosions

F. Disaster Plan

G. Patient Flow in the Event of a Disaster

H. Cardiopulmonary Resuscitation Policy

I. Cardiopulmonary Resuscitation Procedure

6. Hazardous Materials Management 

A. Hazardous Materials

B. Chemical Waste

SECTION V. PERFORMANCE IMPROVEMENT

1. Organizational Performance

A. The Program

B. Program Evaluation

2. Quality Management and Improvement 

A. Objectives

B. Scope of the Program

C. Peer Review

D. Quality Improvement

E. Risk Management

F. The QMI Program

G. Utilization Review

H. Quality of Care

I. Sentinel Events Policy

3. Medical Records 

A. Function

B. Protection and Availability

C. Authentication

4. Infection Control

A. Principles

B. General Rules

C. Infection Control Surveillance

D. Hand Washing

E. Universal Precautions

F. Employee Infection Control

G. Disposal of Sharps

H. Housekeeping Procedures

I. Isolation Techniques

J. Needle Stick Protocol

K. AIDS/HIV Positive Guidelines

L. Biohazard Waste

M. Infectious Waste

 5. Miscellaneous Policies

A. Professional Inquiries

B. Publishing Activities

C. Staff Improvement

D. Teaching

E. Patient Satisfaction Survey

SECTION VI SURGERY

1. Departmental Organization

A. Philosophy

B. Principles

C. Scope of Services

D. Standards of Care

E. Scheduling of Procedures

F. Staffing

2. Administrative Functions 

A. Anesthesia Responsibilities

B. Attending Physician Responsibilities.

C. Surgical Procedures

D. Chart Requirements

3. General Policies and Procedures

A. Prevention

B. Surgical Consent

C. Patient Admission Criteria

D. Monitoring

E. Physician Notification of Change in Patient's Condition

F. Repeat Procedures

G. Transfer of Patient to Hospital

4. Operational Policies and Procedures 

A. Perioperative Nursing Care

B. Intraoperative Patient Care

C. Care of Patient Under Local Anesthesia

D. Administration of Intravenous Conscious Sedation

E. Patient Safety In the Operating Room

F. Asepsis

G. Surgical Preparation

H. Sterilization

I. Infection Control in Recovery Room

J. Patient Discharge Criteria

K. Preparation of Operating Room Equipment

L. Electrosurgical Care

M. Pneumatic Tourniquet Safety

N. Needle and Sponge Count

O. Radiological Safety in the Surgery

P. Venipuncture/Intravenous Infusion

Q. Laser Safety in Practice

R. Latex Sensitivity in Practice

S. Laser Fiber Reuse

5. Environmental Control

A. Supplies

B. Factory Recall of Sterile Products

C. Maintenance of Patient Care Equipment

D. Prevention of Equipment Hazards

E. Waste Gases Management

F. Observing Surgical Procedures

6. Emergency Procedures

A. Emergency Codes

B. Emergency Preparedness Plan

C. Code Procedures

D. Cardiopulmonary Resuscitation Policy

E. Cardiopulmonary Resuscitation Procedure

F. Defibrillation

G. Manual Resuscitation

H. Emergency Tracheostomy

I. Emergency Equipment

J. Physician Incapacitation During Procedure

K. Advanced Cardiac Life Support

L. Required Equipment

M. Obtaining Blood for Emergency Administration

N. Blood Product Administration

SECTION VII. ANESTHESIOLOGY

1. Purposes

A. Philosophy

B. Principles

C. Responsibilities

 2. General Rules and Regulations

A. Standards of Care

B. Staffing and Functions

C. Infection Control

D. Recovery Room

E. Patient Discharge Criteria

3. Operational Policies and Procedures 

A. Post-Anesthesia Follow-Up

B. Safety

C. Anesthesia Gas and Nitrogen Storage

D. Hazardous Materials Exposure

SECTION VIII ANCILLARY SERVICES

1. Radiology Services 

A. Principles

B. Radiation Exposure Monitoring

C. Contrast Reactions 

2. Pharmaceutical Services 

A. Principles

B. Expired Drug Policy

C. Narcotic Policy

3. Pathology and Clinical Laboratory Services 

A. Principles

B. Quality Control

C. Specimens

D. Blood Drawing